Curovate is an app designed by a physical therapist and a group of engineers dedicated to helping you recover after an ACL injury or surgery. Try our mobile app free for 10 days here! Check out what our app users are saying here!

Yes! After your operated knee has healed and after 8-12 months of rehabilitation, you should be able to kneel.

Here are three common reasons why a person may not or feel like they may not, be able to kneel.

Range of motion (ROM):
ROM is a measure of how much you are able to bend or extend a joint. The ROM of your knee before surgery is one of the biggest contributing factors to the ROM of your knee after surgery.1 Generally, you need a ROM of at least 90 degrees in your knee to sit comfortably in a chair. According to a study looking at 100 replaced knees, 64 patients were able to kneel with little to no discomfort if they were able to bend their knee more than 90 degrees.2

Pain:
Even a year after knee replacement it is normal to experience pain or discomfort in your knee, especially when moving it beyond a comfortable range. This is one of biggest factors preventing people from kneeling after they have had knee replacement surgery.3

Fear:
It has been shown that people who have had a knee replacement often do not think they can kneel when they actually can. In a study involving 122 patients, only 36% said they could kneel while 63% of the patients said they could not kneel. When the actual kneeling ability of the patients was measured, 74% of them were able to kneel on the ground without any negative effects. The reasons for the difference in what patients thought they could do and what they actually could do was mostly based on the fear that kneeling would be painful or harmful.4

If you are experiencing discomfort or are worried about the effects of kneeling, please speak to your healthcare provider about your situation.

By completing your rehabilitation exercises every day you will be increasing the ROM of your knee and reducing your likelihood of experiencing pain while keeping yourself on track to being able to kneel again!

Mobile health technology is becoming a common way to access health care services all over the world. Physical therapists have embraced this change to help improve patient outcomes, improve access to physical therapy services and to reduce the administrate burden of providing quality patient care. The ultimate goal of physical therapy is functional independence and a return to your prior level of physical activity. With this in mind your physical therapist may recommend apps that help you along your rehabilitation journey.

More and more people are asking for health care delivered in a manner that suits their life and their needs. Mobile devices are ubiquitous with 4.92 billion users representing 66% of the world population and making mobile devices the most used form of technology in human history.1,2 Further, patients are starting to demand they have access to mobile health technology not as the alternative but as the normal form of care delivery. In 2015, 52% of all health care provider and patient interactions insured by Keiser Permanente, one of the largest health insurance providers in the United States, occurred virtually.3 The potential to access health information and health care visits through our mobile devices is an obvious extension of a technology that has become part of our daily lives. The physical therapy profession has echoed these same sentiments in the Trends and Drivers of Change in Physiotherapy in Ontario report by saying;

“We are seeing a dramatic increase in the use of technology for managing physiotherapy practices, performing marketing functions and delivering effective health care.”4

The same report also urged change for the profession of physical therapy to serve our patients better by stating;

“PTs (physical therapists) that go beyond the standard but archaic photocopied exercise handouts to offer web-based communication platforms can benefit from a more satisfied patient/consumer, and possibly facilitate higher levels of engagement between visits to the clinic to help people achieve their mobility goals.”4

It is with these drivers of change and calls from patients and the general public that we tackled the problem of access to physical therapy services after surgery. One of the most common orthopaedic surgeries for the knee is an anterior cruciate ligament (ACL) replacement. There are 250,000 people in the US who tear their ACL annually.5 The rehabilitation lasts 8-12 months, and poor compliance and long-term health consequences are major challenges following this surgery.6 The compliance rate for rehabilitation is estimated to be 20%.7 This means that 80% of people don’t do the necessary rehabilitation to fully recover! This low compliance rate can lead to poor patient outcomes, more pain and discomfort and future surgical interventions and additional time and money spent by the patient and the health care system.

With the widespread uptake of mobile technology, we have developed a mobile health (mHealth) tool to help improve compliance rates for post-operative rehabilitation.8,9 mHealth has the benefits of being remote, patient-centric, cost-effective, and has the ability to improve health outcomes.10,11 The app called Curovate, has been downloaded more than 1000 times and has had 500 active users in the past 30 days. We have already had patients using the app regularly along with their clinical care and we are seeing great results. Our next step is to conduct a qualitative study to learn more about the feasible, usable, and engagement of patients using mobile health technology for their rehabilitation.

We want to first learn about the lived experiences of the patients who are using our app for their ACL recovery. Our next step will be to conduct a study to evaluate the outcomes of those patients who have regularly used our app for their recovery. We plan to influence health care access, improve the patient experience and satisfaction and also improve patient outcomes after surgery. The app is available in the Google Play Store and can be downloaded here. To further achieve our goal of health care access we have also started this patient education blog that teaches patients about everything related to surgery, recovery and physical therapy. We hope this will be a resource for patients who are having surgery and those that are recovering from injury. The main page of this blog can be viewed here. Here is a brief demo video of our ACL app.

If you have already read part 1 and part 2 of our jumper's knee blog posts now we will show you how you can treat and solve the problem of jumpers knee at home! Watch the video to find out how to do these simple exercises and how often and how many to do every day.

What is Patellar Tendinopathy?
The patella, also known as the kneecap, is connected to the lower leg by a stringy structure called the patella tendon.
Jumper's knee, also known as patellar tendinopathy, is an injury where the patellar tendon gets overworked due to too much stress over time.1 The patellar tendon is put under a lot of stress when jumping, landing, starting, and stopping. When these activities are done too often with a lot of force, the patellar tendon begins to change its structure in a way that causes pain.1 If you want to read more about jumpers knee refer to our previous blog here.

Evidence For Decline Squats
Many studies have shown that lowering yourself down during a squat (called an eccentric movement) on a decline surface is effective for treating patellar tendinopathy. This is likely because for the same amount of work, there is more loading on the patellar tendon, compared to the thigh muscles, when in the decline position2. As long as the decline squat is completed in a controlled manner and not over-done, loading the tendon improves its function.3

Regular Squats vs Decline Squats: One study that looked at regular squats vs. decline squats in 17 patients found that decline squat training caused less pain and lead to a faster return to full function in daily life compared to regular squats.4

One-legged Decline Squats vs One-legged Step Squats: A one-legged step squat is where the back leg is elevated on a step and the front leg is lowering the body. A study completed on 17 volleyball players found that one-legged decline squats were more effective than one-legged step squats for improving pain and the players score on a knee function test after 12 months.5

Horizontal Surface vs Decline Surface: One study completed on 13 people showed that eccentric squats on a decline board worked the patellar tendon 20-25% more than eccentric squats on a flat surface.6 This demonstrates that a decline surface is better at strengthening the patellar tendon.

Protocol For Decline Squat Program or how many and how often should I do decline squats:
One study that researched the best guidelines for treating patellar tendionpathy found that decline squats must be included in the program to help patellar tendinopathy.3 The researchers suggested decline squats should be done twice a day for 3 sets of 15 repetitions based on the results they gathered from 7 other research papers.3 The article found that adding resistance slowly over time helps improve the patellar tendon's function as long as the exercise is done with control, and not done excessively.3

Our next blog post will be a video on how exactly to do decline squats at home with instructions on how to progress.

Let's first explain what a tendon is. A tendon is a strong band like structure made of fibrous tissue called collagen that connects muscle to bone. It has the responsibility of transmitting force from muscle to bone. The patellar tendon connects the bottom of the knee cap (patella) to the shin bone (tibia).1 The patellar tendon can develop small partial tears or complete tears from intense physical activity.1 If the patellar tendon has weakened over time due to activity and improper strengthening then it can be more likely to tear. Now, what exactly is tendinopathy of this tendon? This is what most people call jumpers knee.

Patellar tendinopathy is a common overuse injury that results in a slow increase in pain at the patellar tendon over time. At first, patellar tendinopathy was thought to be inflammation (redness, swelling and pain caused by an injury) of the patellar tendon but further research has indicated that patellar tendinopathy is actually degeneration or wearing away within the tendon.2 That is, the collagen fibers that make up a tendon change in structure and weaken. This happens with overuse which leads to continual micro (very small) tears of the patellar tendon. Having a gruelling training schedule and not allowing enough time of rest can disturb healing of the tendon. Therefore, degeneration of the collagen fibers occurs.2 Patellar tendinopathy is diagnosed as dysfunction and pain associated with the patellar tendon and is often called "jumper's knee."3 This is because activities like jumping produce a large load on the patellar tendon, which if not done properly can overload the tendon. We have a great blog on proper jumping and landing mechanics here. The pain is often just under the knee cap on the upper part of the tendon.

Furthermore, studies have shown people between the ages of 13 to 19 are more likely to get jumper's knee, especially if they are elite athletes.3 Some sports in particular show higher rates of jumper's knee. For example, from a study conducted in the Netherlands, the highest rates of jumper's knee were in recreational and elite volleyball players (14.4%) and lowest rates were for soccer players (2.5%).3

How this condition occurs exactly is still being researched; but there are risk factors related to training habits and personal characteristics that can lead to jumpers knee. The more often an athlete trains per week, the longer the athlete trains for per session and the less rest per session and between sessions increases the chances of developing jumpers knee. Personal factors include: height, weight, alignment of the legs, and strength of the quadriceps (front of the thigh) and hamstrings (back of the thigh) muscles.3

This blog focused on what jumpers knee is and how to avoid it. Our next blog post will tell you what you can do if you already have jumpers knee.

There are many factors that contribute to how a person will recover after ACL surgery. The 4 major factors for recovery are listed below. The first 2 are things you can control or work on to improve your recovery. The last 2 are factors that you do not have control over.

1. Ability to bend the knee fully before surgery
A study that looked at factors affecting recovery after ACL surgery found that people who were able to bend their knee all the way before surgery had faster recoveries than those who could not bend their knee all the way.1 Fortunately, physiotherapy treatment can help improve your ability to bend your knee before and after surgery. Our app Curovate can also help your ability to bend your knee.

2. Strength of muscles around the knee
The strength of the muscles that move the knee can predict how long it will take to recover. The faster the injured knee regains strength equal to the unaffected knee after surgery, the better the outcome is 1 year later.2 It is especially important to regain strength in the hamstring muscles (at the back of the thigh that help bend the knee). Weak hamstring muscles increases the risk of re-injuring the ACL.3 The exercises in our app Curovate can help you regain your strength.

3. Age
You may have heard before that young people heal much faster than older people. This happens to be the case when it comes to ACL surgery and getting back to all of your activities. Surgery is sometimes avoided in older people because of a higher complication rate compared to younger people.4 A study on 104 patients that underwent ACL surgery found that 12 months after ACL surgery, patients who were 20 years old or younger needed less rehabilitation time than patients over 20 years old. The younger patients had less pain, less swelling, better mobility, and strength and returned back to their normal level faster.5

4. Other injured structures in the knee
There are 4 major ligaments that stabilize the knee: ACL, PCL, MCL, and LCL. The ACL can be injured alone but in more severe injuries, other structures can be torn as well. One study showed the patients who had torn multiple ligaments had a longer recovery time compared to just tearing their ACL alone.5 This is because multiple ligament injuries might require more procedures, have more pain and symptoms, and also require more time before the patient can move after surgery.5

Other common factors that have been studied with regards to how a person will recover from ACL surgery include gender, body mass index (BMI - a ratio of height to weight), and type of ACL graft used. These factors do not have a strong influence on the rate of recovery.6

Struggling with motivation to keep up with your exercises at home? Look no further!

Previously we discussed some of the reasons why people find it challenging to do their rehabilitation exercises. We looked at how fear and pain (Part 1) or a lack of time and equipment (Part 2) can affect a person’s willingness to do their exercises to recover after injury or surgery.

Staying motivated and enjoying your rehabilitation program is critical to recovery. I will discuss how these two factors effect a patient’s commitment toward their rehabilitation and include tips from our physical therapist to help you along the way.

Motivation

Motivation is having the desire to do something.1 We tend to do things because it is personally rewarding to us, or for an external reward like money or a trophy. In the case of exercising at home after injury or surgery, motivation is a huge factor that determines your success. Some people need an outside influence to maintain and/or increase their motivation, such as the presence of their physical therapist or other health care provider.2 For this reason, a lack of self-motivation is a barrier to completing exercises on their own.

Some people have higher levels of intrinsic motivation, which can be thought of as being “self-motivated,” and are more likely to complete their home exercises.3 The more motivation you have on your own, the more likely you will do your exercises at home without your physical therapist and increase your chances of a successful recovery.

Physical therapy advice - After reading the section above many of you might be thinking, "I am not one of those self-motivated people! What can I do?"
Here are some tips I have learned from working with patients over the past 17 years and brilliant suggestions from my patients who have figured out the key to their own personal motivation:

Set an achievable goal! If you love soccer and you want to get back to playing let that be your long term goal after injury or surgery. In rare cases returning to sports is not recommended after injury or surgery but this can be discussed with your health care provider.

Find other people who have gone through the same thing and talk to them about their journey. This can be done face to face but more and more people are finding this community and support on-line. One of these examples is the ACL Recovery Club which is an on-line community for people after ACL injury or surgery. It helps to know others have gone through the same challenges and have had successful recoveries.

Give your self real or virtual rewards! Yes it sounds odd but even virtual rewards that are meaningful to you can make you more motivated. We have a simple system of stars and trophies within our ACL app that helps people stay motivated to do their daily exercises. Research has shown that even virtual rewards are effective to motivate people.

Track your progress! It is hard to be excited about knee movements or being able to lift your leg without pain but these will be some of your initial goals after surgery. Having a method to track your progress either on a piece of paper, a chart or an on-line or app tracker will keep you motivated. When you use our ACL app it tracks all of your progress daily for your exercises, knee movements, and achieved goals without ever having to write anything down. The easier it is to track your progress the more likely you will be to continue doing it!

Lack of enjoyment

When it comes to completing your rehabilitation exercises there may be times where you feel like you would rather be doing something else, especially if you are doing your exercises at home by yourself. After an ACL injury, most of the exercises given to patients by their physical therapist are low-intensity and may not be very exciting depending on the stage of recovery. Some people report that the exercises they do are “boring, mundane, and a waste of time,”2 and this discourages them from following their rehabilitation program. In order to commit to your rehabilitation program, it is important that you enjoy what you are doing, especially since recovery takes months and not days.

Physical therapy advice - This is a tough area to advise patients since I can't make anyone love their exercises. Here are some tips that can help:

Pair your exercises with an activity that you love. You can do your exercises while watching your favourite show, listening to some great music or a podcast or watching a sporting event on tv.

Make sure that you have a long term goal that will make the exercises that you are doing have some purpose and meaning. It is hard to enjoy leg raises but if you know that this will let you be more independent in walking and eventually jogging this might lead to you enjoying your exercises. In our ACL app jogging starts at 3 months!

Look into the future! It is important to remember why you are doing your exercises. Look at the later stages of your rehabilitation and this might get you excited about what you can do in a month or 3 months. Our ACL app provides you with weekly goals on the "Journey" page and this feature allows you to look at your goals currently but also throughout the entire rehabilitation process.

Do your exercises in a place that you love. Some people love the gym and some people love their living room. I encourage these people to workout in that space so that they feel better about what they are doing. Even if this means going to the gym to do knee bending exercises.

Remember this process is hard but the exercises have been designed to allow you to return to all of those activities that you love.

If you have had or are going to have a knee replacement, then you have probably wondered about what kind of exercises and sports you will be able to do when you have recovered.

It is important to begin a knee replacement rehabilitation program as soon as possible after surgery. The faster your operated leg regains its strength and flexibility, the more likely you will be to see improvements in your independence and with activities of daily life.1

At 13 to 16 weeks after knee replacement surgery, it would be a good time to begin some endurance activities but there are some requirements before you start:

You must have minimal to no pain in your knee.

You must have minimal to no swelling in your knee.

You must be able to bend and straighten your leg almost as well as your non-operated leg.

You must be able to walk fast without walking aids (walker or cane) or limping.

You must be able to walk for 20 minutes without experiencing pain or swelling.

Speak to your healthcare provider before beginning any new exercises, especially if you are not sure if you meet the five requirements listed above.

The charts below provides recommendations for patients following knee replacement 13-16 weeks AFTER surgery. These charts have been adapted from a clinical commentary released by the Journal of Orthopaedic and Sports Physical Therapy in 2008. A clinical commentary is written by a group of clinical experts when there is no definitive answer provided by research. This means that there isn't a study that says "golf is safe after 16 weeks." So a group of experts decided this based on what they know and the research that is available.

Our physical therapist, Nirtal Shah, states: "Some of these activities may be possible before 13 weeks such as stationary biking, others around 13 weeks such as swimming and some may take 8-12 months such as golf, skiing and doubles tennis. This is a guideline and should be used with the guidance of a healthcare provider."